NURSING PRACTICE I

Situation 1: Loss and grief affect not only the clients and their families but
also the nurses who care for them. It is essential for the nurse to have a
thorough understanding of a clients loss and the meaning of the loss to the
client.
1. A 55-year-old client is terminally ill with advanced cancer of the
ovary. To assist and comfort her, the nurse should
A.
B.
C.
D.
2.

3.

Attend to her physical needs

Provide support to the client
Assess continuously the clients condition
Assess the clients understanding of her illness and
impending health

Upon learning about her condition, the client says to the nurse,
Why me? I did not do anything wrong. What response of the
nurse is most appropriate?
A. You will be fine.
B. Death is a normal part of life.
C. This must be very difficult for you.
D. Everyone has to die sooner or later.
The client is in severe pain and manifests signs of impending
death. The husband asks the nurse if his wife is going to die soon.
Which of he following is the most appropriate response of the
nurse?
A. The signs do not predict the exact time frame of
death.
B. You are concerned that your wife will die?
C. Death is inevitable.
D. Are you worried that your wife will die?

4.

The client has just died with her family around her. What
appropriate nursing action should the nurse make?
A. Allow the family time to be with the deceased client
B. Allow the family to grieve
C. Give the personal belongings of the client to her family
D. Reassure the family that the body will be cared of

5.

The body is being prepared for transfer to the mortuary. Which of

the following is the most appropriate action of the nurse?
A. Remove all contraptions.
B. Record the time of death
C. Secure all belongings in a plastic bag
D. Bathe the body and place identification tags

Situation 2: In teaching good sleep hygiene to adult clients, the nurse

encounters clients in variety of situations that need some guidance and
assistance
6.

When talking to a client to assess her sleeping difficulties, the

nurses most therapeutic communication would be
A. Is this room darkened at night?
B. Do you take naps during the day?
C. What do you do just before going to bed?
D. Do you take snacks prior to going to bed?

7.

To promote good sleep hygiene, the nurse teaches the client to do

the following except
A. Avoid a heavy meal 3 hours before bedtime
B. Use the bedroom only for resting and sleeping
C. Stay in bed if sleep does not come in 30 minutes
D. Limit the use of bedroom for intensive work, studying,
eating, or watching TV

8.

The client is concerned that sleeping during the day and being
awake at night is abnormal and unhealthy. The nurses most
therapeutic response is
A. Many people who work at call centers have the same
habits and they are alright.
B. People have different biological clocks. As long as you
sleep and function well, your habit is not abnormal and
unhealthy
C. Would you like to change your sleeping habits at this
time?
D. What makes you think that your habit of sleeping
during the day and being up at night is unhealthy and
abnormal?

9.

Which of the following questions by the nurse will help identify

possible causes of clients sleep problems?
A. How long does it take for you to fall asleep after you
lie down?
B. What do you do to fall asleep at your desired
bedtime?
C. Have you changed your bedtime rituals lately?
D. What time do you usually sleep?

10. The client has obstructive sleep apnea (OSA) and has disrupted
sleep. He asks the nurse about the possible serious
consequences of OSA. The nurses most appropriate response
would be the following except
A. Alzheimers disease
B. Cerebrovascular accident
C. Cardiac dysrhythmias
D. Hypertension
Situation 3: Total quality improvement is based on the premise that the
process is ongoing and that quality can be always improved.
11. While giving care to a client in a medical unit, the nurse observes
that a 65-year-old male bedridden client has a reddened area with
no break in the skin in his coccyx. A clean dressing has been put
over the site in order to
A.
B.
C.
D.

Protect the area from injury

Provide comfort to the client
Make healing faster
Allow light to get through

12. A bedridden client has nasogastric tube and an intravenous line.

The client appears disoriented and attempts to remove both
contraptions. What action should the nurse do to protect the client
from injuring himself?
A. Ask a family to stay with the client
B. Stay with the client
C. Apply restraint
D. Ask the physician for an order for wrist restraints
13. The nurse is caring for a client receiving chemotherapy. She is
concerned about the clients nutritional status and aims to
improve the appetite of the client. The nurse should
A. Administer medications before meals
B. Improve the food flavor
C. Offer hot soup
D. Offer white meat
14. The nurse is evaluating the nutritional status of a client. Which of
the following parameters should be observed by the nurse?
A. Stable weight
B. Extent of nausea and vomiting
C. Improved appetite
D. Amount of food intake
15. While completing the final preparations for a 12-year-old who is
scheduled for appendectomy, the nurse sees the mother applying
hot water bag in the childs abdomen for relief of pain. The nurse
should tell the mother that the hot water bag may
A. Arrest progression of the disease
B. Increase abdominal contraction
C. Increase abdominal peristalsis
D. Cause the appendix to rupture
Situation 4: The nurse is assigned to take care of a client with an
endotracheal tube. The nurse noticed thick secretions
16. Which of the following is the most appropriate nursing intervention
to loosen the secretions?
A. Instill Mucomyst into the endotracheal tube and
frequent turning of the client unless contraindicated
B. Perform chest physiotherapy and assess respiratory
status of the client
C. Administer humidified oxygen and place the client in
side-lying or prone position unless contraindicated
D. Increase fluid intake and frequent turning unless
contraindicated

17. In performing endotracheal suctioning, the nurse should apply

suction while
A. Rotating the catheter gently for not more than 10
seconds
B. Observing the amount and character of the secretions
after each suctioning
C. Observing the clients tolerance to the procedure
D. Assessing the clients respiratory and circulatory status
18. The nurse is monitoring the cuff pressure. To minimize the risk of
tracheal tissue necrosis the nurse should maintain the pressure to
A. 10 15 mmHg
B. 20 25 mmHg
C. 30 35 mmHg
D. 40 45 mmHg
19. The nurse is providing oral and nasal care every 2-4 hours to the
client. As a precautionary measure for possible biting down of the
oral endotracheal tube, the nurse should
A. Have an assistant to hold the client
B. Use an oropharyngeal airway
C. Provide humidified air prior to the procedure
D. Position the client to side-lying position
20. The head nurse reminds the staff nurse about measures that
must be strictly observed when suctioning the client with an
endotracheal tube. Which of the following is the most appropriate
measure during suctioning?
A. Using rubber gloves when doing suctioning
B. Suctioning while inserting the catheter
C. Suctioning 2-3 times before withdrawing the catheter
D. Hyperoxygenating the client before and after the
procedure
Situation 5: The following situations are opportunities for the nurse to give
health teachings to the client and his family members.
21. A client who had a cerebrovascular accident resulted in rightsided weakness of the extremities and mild slurring of speech.
The nurse is assisting the client to ambulate. To prevent the client
from falling, the nurse should stand at the
A. Left side with one arm around the clients waist
B. Right side and holding the clients arm
C. Right side with one arm around the clients waist
D. Left side and holding the clients arm
22. The use of principles of body mechanics is important when taking
care of clients. To prevent injury to self and others, the nurse
teaches the family members to do which of the following?
A. Move about a feet away from the client if possible
B. Form a broad base of support, flex the knees and feet
wide apart.
C. Use back and arm muscles to support lifting or moving
objects
D. Bend from the waist with knees straight and feet wide
apart
23. The clinic nurse in a large factory teaches some exercises to
some office workers. Which of the following statements is the
most appropriate?
A. Exercises can easily burn and expend daily caloric
intake
B. The best cardiovascular activity is walking on a
treadmill
C. Less intense or not very tiring exercises should be
done frequently to be of value
D. Continuous activity for a long period of time is useful
as an exercise
24. An elderly client has been taught how to use crutches in going up
and down the stairway. You observe that the clients use of
crutches is appropriate when he
A. Uses the crutch next of the affected leg when going up
or down the stairs
B. Advances the crutches first to go up the stairs then the
affected leg
C. Uses the stair banister for support while going up or
down the stairs
D. Advances the crutches to go down the stairs then
move the affected leg afterwards

25. A mother calls the emergency unit to ask for advice after she
found her child seated on the bathroom floor with cleanser around
her mouth and tongue. The appropriate advice given to the
mother would be to
A. Check if the child is breathing and if the airway is open
B. Give the child syrup of Ipecac to induce vomiting
C. Call the poison control of a general hospital
D. Remove cleanser from the mouth and tongue
Situation 6: A 21-year-old female is admitted to the Surgery Ward and is
placed in traction. She has been very frustrated because she cannot do her
usual daily activities.
26. The nursing diagnosis that is most appropriate for this client is
A. Potential for immobility
B. Impaired physical mobility
C. Activity intolerance
D. Risk for injury and pathologic fractures
27. Limitations in the activity exercise routine of a client affect her
self esteem. To help increase the clients self esteem, the
nurse understands that
A.
B.
C.
D.

Self esteem depends upon having a feeling of

usefulness and independence
Being confined in bed with no productive activity
causes depression
Self esteem is dictated by ones state of physical
health and beauty
The current problem exacerbates the clients already
low self-esteem

28. The nurse maintains the clients good body alignment while she is
in traction in order to
A. Promote proper body balance and optimal brain
functioning
B. Maintain body posture and strength
C. Promote efficient circulation and enhance lung
expansion
D. Decrease workload of the heart
29. The nurse considers the following statements when taking care of
a client with traction except
A. Steady pull from both directions keep the fractured
bone in place
B. Weights should be kept resting on the floor
C. Clients on traction need adequate skin care and proper
positioning
D. Traction can be used to correct or prevent deformities
30. Part of nursing care for a client on traction is giving instructions for
isometric exercises in order to
A. Prevent decubitus ulcers
B. Improve lung capacity
C. Normalize blood pressure
D. Maintain muscle strength
Situation 7: An understanding of the infectious process and appropriate
methods to protect the health workers and client from disease is important.
The following questions pertain to preventing transmission of infection.
31. The nurse is explaining standard precaution to the client. This
includes which of the following actions?
A. Wearing protective equipment when doing any nursing
procedures
B. Handwashing using antimicrobial soap and water
C. Recapping of used needles with both hands then place
in puncture-resistance container
D. Using clean gloves to handle contaminated items,
blood and excretions
32. The nurse is changing the wound dressing of a client. The most
appropriate action of the nurse would be to
A.
B.
C.
D.

Remove old dressing with sterile gloves

Wear sterile gloves whenever in contact with the area
Open the sterile dressings with sterile gloves
Pour antiseptic solution out of the container with sterile
gloves

33. The client has an order for contact precaution. The nurse is to
give her a bath. The precautionary measure that the nurse
observes is to use
A. Face mask and gloves
B. Sterile gloves and cap
C. Gloves and gown
D. Cap and face mask
34. The clinical instructor in the surgical unit is teaching the nursing
students about the prevention of spread of diseases in the health
care environment. Which of the following is the most important
practical way to prevent the spread of diseases?
A.
B.
C.
D.

Consistently washing hands

Isolating infected clients
Wearing gloves whenever giving care
Wearing cap and gown

35. The nurse is to perform a sterile procedure while assisting in a

minor surgery. Which of the following actions of the nurse
maintains aseptic technique?
A.
B.
C.
D.

Keeping the sterile field in view

Handling the medicine to the physician over the sterile
field
Talking to others over the sterile field
Using sterile gloves in opening sterile package

Situation 8: Nursing interventions are sometimes complex and require

knowledge and skills. Other nursing interventions are relatively simple and
can be delegated to assistive personnel. One of the key skills of an effective
nurse leader is delegating tasks effectively.
36. The head nurse is evaluating the performance of the nurses in all
the service units. Which of the following is the key activity in
evaluating the performance of nurses?
A. Communicate clearly to the nurse the purpose of
performance appraisal at the time they are hired
B. Provide input to nurses in developing the standards in
which performance is judged
C. Inform nurses in advance what happens if the
expected performance standards are not met
D. Reinforce the nurses prior achievement to help find
new ways to excel
37. Upon reporting to the unit, the head nurse of the morning shift is
overwhelmed with the following situations: failure of the staff to
carry out medication order 2 days ago, an elderly client pulled out
his central venous line and a client wishes to be discharged
immediately. Which of the following should be the course of action
of the nurse?
A. Increase the scope and responsibility of the staff nurse
B. Recognize the capability of each team member and
delegate appropriately
C. Prepare an assignment of each team member and
delegate appropriately depending on the expertise of
the member
D. Assess the situation and delegate appropriately
activities that recognizes the unique expertise of each
team member
38. Managers implement a variety of strategies to ensure effective
delegation. The following are strategies that ensure effective
delegation except
A.
B.
C.
D.

Assess the situation and delineate expected outcome

Identify the skills and educational levels of the team
necessary to complete the job
Empower the person to whom you delegate the job
Create job description and scope of responsibility

D.

40. A staff nurse in the emergency room is well-liked by her

colleagues because she could easily relate well with co-workers.
For the past 2 months, she has been absent 4-5 times. She had
been given a written admonishment for unexcused absences.
Which of the following is the best course of action of the head
nurse?
A.
B.
C.
D.

A.
B.
C.

Lack of experience in delegating and trying to get

organized
Delegating without adequate information
Feeling insecure in their ability in performing task

Warning
Suspension
Dismissal
Verbal admonishment

Situation 9: A nurse in the medical unit suspects that a colleague is abusing

chemicals while on duty. Irregular reports on the narcotic medication sheet
are noted when she is on duty.
41. Which of the following should be the appropriate action of the
nurse?
A.
B.
C.
D.

Report to the supervisor in a confidential manner

Pretend not to know the situation
Personally call her attention in private
Write an incident report and submit to administration

42. To be vigilant when a co-worker is suspected of abusing

chemicals, it is imperative for the nurse to assess which of the
following substance abuse indicators?
1.
2.
3.
4.

Defensive when questioned on the discrepancies in the

narcotic control sheet
Excessive work-related tardiness, absences and accidents
Accurate but sloppy documentation
Social isolation
A.
B.
C.
D.

1, 2, 3, and 4
1 and 3
2 and 4
1, 2, and 3

43. Health care agencies have policies in place for Do Not

Resuscitate (DNR) decisions when the client is either comatose
or near death. In this situation, which of the following should be
the responsibility of the nurse?
A.
B.
C.
D.

Know and follow the patients wishes regarding

resuscitation and the application of life support system
Ascertain that a written DNR order from the physician
is in place
Explain to the family the consequences of DNR
Follow strictly the physicians order

44. Which of the following should the nurse take into consideration
when the client has a DNR order?
A.
B.
C.
D.

The DNR order is not separate from other aspects of

clients care
The order of the physician is final and not subjected to
explicit discussion
The competent clients values and choices should
always be given the highest priority
Consider the views of the family who are against DNR

45. A nurse in the cancer unit is in a quandary in carrying out a DNR

order due to personal beliefs. Which of these is an appropriate
nursing action in this situation?
A.
B.

39. The nurse manager delegates work to a subordinate. Which of

the following is the frequent mistake made by the manager in
delegating?

Over-delegating, under-delegating and improperly

delegating

C.
D.

Seek counseling session with the nurse supervisor on

duty
Seek comfort and allay ones fears through stress
management
Ignore personal beliefs and feelings in the situation
Consider a change of assignment

Situation 10: A nurse is a member of the multidisciplinary health team. In

working with the team, client and family are important considerations in the
formulation of goals and planning of care.

46. Doctors orders are medical interventions that the nurse is

expected to implement. By education and training, the nurse may
choose not to follow doctors orders. Which of the following
statements is not true?
A.
B.
C.
D.

The nurse has less training than the doctor and

clarifying an order is against hospital protocol
By carrying out a wrong order, the nurse is just as
liable as the person who wrote the order
Clarifying an order is competent nursing practice and
protects the client from potential harm
The knowledge base of the professional nurse allows
her to recognize errors and try to correct it

47. The nurse carries out nurse-initiated interventions which are

referred to as independent functions. These functions are
A.
B.
C.
D.

Actions based on nursing diagnoses for the benefit of

the client and not under supervision from other health
team members
Nursing orders that require specialization in certain
fields of nursing practice to implement
Focused only on health restoration and administration
of medications
Tasks performed by the nurses who have attained
higher degree of education and specialty training

48. A client sustained multiple injuries from a vehicular accident. To

maintain his level of health, he will need the health team. Which of
the following illustrates this kind of interventions?
A.
B.
C.
D.

Nurse-initiated
Collaborative
Support system
Doctor-initiated

49. A new staff nurse is attending an orientation program. The

supervisor emphasizes close collaboration with the heath team as
an important function of the nurse. The nurse demonstrates this
when she
A.
B.
C.
D.

Identifies the community health centers that the client

can visit when discharged
Leaves the decision-making to the doctor who is the
recognized leader of the multidisciplinary team
Creates a discharge plan as soon as the client is
admitted to the ward
Shares her knowledge and expertise with other nurses
and solicits the expertise of others

50. A client is admitted with a medical diagnosis of acute

gastroenteritis with severe dehydration. The nurse recognizes that
when caring for this client, she will be doing mostly
1.
2.
3.
4.

Dependent nursing functions

Independent nursing interventions
Discharge planning with the physician in charge
Delegation of nursing functions to the nursing aide
A.
B.
C.
D.

1, 2, and 3
2 and 3
1 only
2, 3, and 4

Situation 11: Problems with bowel movement may be experienced by people

of different ages. It can cause enough discomfort or health problems to
individuals that require nursing interventions.
51. An active woman in her mid-20s has been on weight loss diet of
low-carbohydrates and high protein diet. She is successful in
losing weight but is experiencing constipation. Which of the
following should the nurse advice the client to avoid constipation?
A.
B.
C.
D.

Take over-the-counter laxatives to ease bowel

movement
Try another type of diet that has less animal fat like
fish, chicken, and low-carbohydrates
Eat nutrient-dense foods that are low-calorie but have
high nutrient value and fiber like broccoli and berries
Increase exercise activities to improve peristalsis

52. You are administering soapsuds enema to a client. During the

procedure, the client complains of abdominal cramping. Your most
appropriate initial nursing approach would be to
A.
B.
C.
D.

Clamp the enema tubing to stop the flow of fluids

Push the tubing further by 2 inches
Ask the client to inhale and exhale slowly
Lower the height of the enema container

53. You are taking care of a client with fecal incontinence. You are
aware that this client has a risk for injury due to
A.
B.
C.
D.

Falls when trying to go to the bathroom

Dehydration and malnutrition
Increased abdominal cramping
Perineal and anal skin breakdown

54. A client is brought to the hospital due to severe diarrhea. Which of

the following is a major problem of the client requiring immediate
management by the health team?
A.
B.
C.
D.

Excessive passing of flatus

Irritation of the anal sphincter
Severe abdominal cramping
Severe fluid-electrolyte imbalance

55. A client had abdominal surgery under general anesthesia and is

still in the recovery room. You are aware that clients who went
through general anesthesia would most likely experience
A.
B.
C.
D.

Paralytic ileus
Tolerance for solid food immediately after surgery
Immediate return of gastrointestinal motility
Excessive flatus

Situation 12: A researcher investigated the effect of crossing of a leg at the

knee during blood pressure measurement of a clients blood pressure.
Participants were recruited from the outpatients of a government training
hospital consisting of 50 males and 50 females, 21 to 70 years of age with a
diagnosis of hypertension.
56. Which of the following describes this type of research?
A.
B.
C.
D.

Qualitative research
Applied research
Quantitative research
Basic research

57. The researcher explains to the participants the nature of the

study. Which of the following describes the action of the
researcher?
A.
B.
C.
D.

Full disclosure
Informed consent
Human dignity
Self-determination

58. The research question for this study may be stated as follows:
A.
B.
C.
D.

What is the blood pressure of the participants before

crossing a leg at the knee?
What is the effect of crossing a leg at the knee on the
blood pressure of the participants?
What is the initial blood pressure of the participants
with a leg crossed at the knee?
What should be the position of the leg when measuring
blood pressure?

59. Which of the following is the appropriate instrument in measuring

the dependent variable?
A.
B.
C.
D.

Self-report method
Participant observation
Biophysiologic measures
Observational rating instrument

60. The researcher found out that the blood pressure measurements
are higher when a leg is crossed at the knee and that the

probability is less than 1 in 10,000. With these findings, the

researcher concludes that

C.
D.

A.
B.
C.
D.

There is an increase in blood pressure when a leg is

crossed at the knee
The blood pressure decreases when a leg is crossed
at the knee
There is no change in the blood pressure reading
when a leg is crossed at the knee
Crossing the leg at the knee is significantly related to
the blood pressure

Situation 13: Teaching clients about healthy food intake for health promotion
and disease prevention is an important function of the nurse. Nutritional
deficiency is preventable if individuals and families have adequate
knowledge about normal nutrition.
61. The nurse is teaching a family to take food with high protein
content. She discovers that the familys consideration is the high
cost of food. Which of the following affordable high protein foods
should the nurse recommend?
A.
B.
C.
D.

Peas and beans

Beef steak and vegetables
Fried rice and dried fish
Spaghetti and bread

62. During the follow-up visit, the client asks the nurse foods that are
complete in protein. Which of the following should the nurse
recommend?
A.
B.
C.
D.

Oatmeal with raisins

Toast with peanut butter
Eggs cooked in any style
Lentil soup

63. A mother asks the nurse what finger food is safe for her toddler.
Knowing that children can easily choke on food, the nurse should
advice the mother to feed the toddler which of the following
foods?
A.
B.
C.
D.

Caramelized popcorn
Cereals like cheerio
Grilled hotdog
Salted nuts

64. A client diagnosed with peptic ulcer asks you what food is best to
add to his diet so as not to exacerbate his symptoms. Which of
the following is the most appropriate food for this client?
A.
B.
C.
D.

Citrus fruit juices

Caf latte and similar drinks
Green vegetable drinks
Frequent intake of milk

65. A mother asks if teenagers require special diet since teenagers

rapidly grow at this time. The nurse informs them other that
A.
B.
C.
D.

Boys need more fat and carbohydrates because they

are more active than girls
Girls should increase intake of food rich in vitamins A,
D, E, and K
Boys and girls should have food low in calories to
prevent adolescent obesity
All teenagers need high-protein diet

67. A female client is in the emergency room with chief complaint of

difficulty breathing and is receiving oxygen inhalation. To obtain a
complete history of the client, the best nursing approach is to
A.
B.
C.
D.

66. While taking the health history of the client, she tells the nurse
that she has occasional episodes of palpitations that would last
for about 45 minutes to 1 hour. To further explore this information,
the best question that the nurse should ask would be
A.
B.

What are you doing or whats going on around you

when this happens?
Are there other symptoms you experience along with
this?

Focus on the physical examination and obtain other

data from the client
Use the medical history taken by the physician
Have several short sessions with the client to gather
data needed
Call family members to provide additional information
about the client

68. A client has just been transferred to the surgical unit after knee
surgery. The nurse needs to assess the circulation of the right
lower leg. Which of the following is the initial approach of the
nurse?
A.
B.
C.
D.

Check pedal pulse with your fingertips

Inspect color of the foot
Touch affected leg to check temperature
Take blood pressure at the ankle

69. While performing a physical examination to an 82-year-old male

client, the nurse modifies her examination to consider the clients
general weakness and reduced ability to move in bed. Which of
the following is the most appropriate nursing action?
A.
B.
C.
D.

Sequencing the examination to minimize changing

clients position
Examining the client only in the position where he is
comfortable
Avoid touching the client so as not to alienate the client
Speak loudly and close to the ear when talking to the
client

70. The nurse is auscultating the clients heart. Which of the following
is the best position of the client to enable the nurse all areas and
high-pitched murmurs?
A.
B.
C.
D.

Sitting and leaning forward

Left-lateral recumbent
Supine
Lying-in-bed

Situation 15: A male nurse meets a 55-year-old client in his room. During
interaction, the nurse feels drawn to the client and later looks forward to
seeing the client daily as does his rounds. The nurse realizes that the client
looks and acts like his grade school teacher who was kind and fatherly
towards him.
71. Which of the following best describes the feelings that the nurse
experienced towards the client?
A.
B.
C.
D.

Counter-transference
Transference
Denial
Idealization

72. The nurse utilizes the concept of therapeutic use of self when she
A.

Situation 14: Physical examination is performed to gather comprehensive

pertinent assessment data. Health history ascertains the clients complaints
and directs the focus of physical examination

Does the hear problem occur at any specific time of

day?
How frequently does this episode of palpitation
happen to you?

B.
C.
D.

Becomes self-aware and manages his feelings for his

clients
Discusses his personal feelings with the client
Asks to be assigned to another client
Ignores his feelings and continues to take care

73. The client is informed that he has stage IV colon cancer. He

realizes he is dying and his family has difficulty with his impending
death. The nurse deals with his own personal feelings about
death and grieving in order to
A.
B.

Discuss the familys plan for the funeral and burial

services
Assist the client and family express feelings on their
impending loss

C.
D.

Remain objective and protect himself from the grieving

process
Shield his personal thoughts and feelings of loss and
grief

A.
B.
C.

74. One afternoon the nurse enters the room and the client tells the
nurse, Stop bothering me. Leave me alone. I dont want anyones
pity. The most appropriate response of the nurse is to say
A.
B.
C.
D.

What did I do to upset you? Why are you angry with

me?
Alright, I understand and I will leave you for a while.
Are you upset because you dont feel well?
You seem upset, and remains with the client

75. A therapeutic relationship exists when the

A.
B.
C.
D.

Nurse and client work together to talk about how

clients needs may be met
Nurse informs the client the goals and priorities for his
care after a thorough assessment
Nurse explores the clients thoughts and actions for the
clients benefit
Various nursing procedures are used to help meet the
clients needs

D.

Situation 17: The medical ward has clients with various disease conditions.
As a newly hired nurse, you are challenged to update knowledge and skills in
the provision of nursing care.
81. When administering oxygen therapy to a client, the least likely to
cause anxiety is the use of
A.
B.
C.
D.

A.
B.
C.
D.

Read the literature for directions

Secure assistance before implementation
Observe other clients with similar situations
Interview nurses about their experiences with the PCA
pump

77. The focus of care is to shorten hospital stay by moving clients

from an acute care setting to a community-based care setting.
Which of the following are the components of health care delivery
that are important to improve the health of the general public?
A.
B.
C.
D.

Community health nursing and community-based

nursing
Hospital-based nursing and community health nursing
Acute care and community health care setting
Acute care in the hospital based setting

78. When a nurse acts professionally, it implies that she

A.
B.
C.
D.

Is dedicated and committed in the practice of her

profession
Considers health care cost and provides that best
evidence-based practice
Is knowledgeable, conscientious and responsible to
self and others
Uses clinically documented evidences in decisionmaking

79. Nursing as a profession requires its members to possess a

significant amount of education. The route for an individual to
become an RN in the Philippines is through completion of a
A.
B.
C.
D.

Basic science including theoretical and clinical courses

Degree of Bachelor of Science in Nursing and eligible
to take the Nurse Licensure Examination
Formal four-year course leading to Bachelor of
Science in Nursing
Bachelor degree in a hospital setting and eligible to
take the Nurse Licensure Examination

80. To remain current in nursing skills, knowledge and theory, a nurse

who works in a geriatric unit plans to attend a continuing
education program (CPE) in the care of elderly clients. The
following statements about CPE are true except

Face mask
Oxygen tent
Nasal catheter
Nasal cannula

82. Which of the following is a major consideration in determining the

method of oxygen administration to a specific client?
A.
B.
C.
D.

Situation 16: Continuous personal and professional development of the

nurse is expected to provide safe quality care to clients
76. A post-surgical client assigned to the nurse has an order of pain
medication through a patient-controlled analgesia (PCA). The
nurse has no prior experience in the use of PCA with clients.
Considering the time frame, which of the following is the most
appropriate action of the nurse?

CPE aims to improve and maintain safe nursing

practice
CPE assures that nurse possess a significant amount
of education
It is a response to scientific and technological
advances to make nurses globally competitive
It ensures professionalism in nursing and improves
personal qualities and professional behavior of the
nurse practitioner

Pathologic condition of the client

Facial anatomy of the client
Age of the client
Mental capacity of the client

83. The nurse is assisting a client who has an order for postural
drainage. To help the client obtain maximum benefits after the
procedure, the nurse should
A.
B.
C.
D.

Encourage the client to cough deeply

Allow the client to rest in a sitting position
Elevate the head of the bed to promote comfort
Allow the client to stay in his position for 30 minutes

84. When doing postural drainage for the client, measures should be
taken to minimize which of the following conditions?
1.
2.
3.
4.

Fatigue and pain

Dsypnea
Anxiety and discomfort
Coughing
A.
B.
C.
D.

1 and 2
1, 2 and 3
1, 2, 3 and 4
1, 3 and 4

85. The nurse is taking care of a client with asthma. During

auscultation, she expects to hear wheezing sound which would
sound like
A.
B.
C.
D.

Grating sound
Coarse crackles or rales
High pitched musical sounds
Loud low pitched sounds

Situation 18: A 73-year-old client is brought to the emergency room for

passing fresh blood upon defecation. The client is actively bleeding and his
blood pressure drops to 80/50 mmHg. Fluids and blood transfusion of
packed RBC are ordered immediately.
86. This is the first time that the client will have blood transfusion. He
and his family are very worried about the procedure. Your most
appropriate nursing intervention would be to
A.
B.
C.
D.

Talk to the client and family and inquire what their fears
are about blood transfusion
Reassure the client and family that blood transfusion is
a simple low risk procedure
Tell the client that he will be closely observed for the
first hour so he will be safe
Request the doctor to explain to the client why blood
transfusion is necessary

87. The nurse prepares the following equipment for blood transfusion
except
A.
B.
C.
D.

0.9% normal saline solution

IV infusion set with gauge 22 needle
Blood product properly typed and cross-matched with
the client
Y-type filter transfusion set

88. The nurse understands that normal saline solution is used to

initiate the intravenous infusion rather than dextrose solution
before blood transfusion to
A.
B.
C.
D.

Avoid cardiac overload

Maintain adequate hemoglobin content
Prevent increasing the blood sugar
Avoid hemolysis and clumping of RBC

89. The nurse stays and observes closely the client after the start of
the blood transfusion for possible transfusion reaction which
includes the following except
A.
B.
C.
D.

Hypovolemic reaction
Febrile reaction
Hemolytic transfusion reaction
Allergic reaction

90. After starting blood transfusion, the nurse should make sure that
the blood is transfused to the client within how many hours from
the time it started?
A.
B.
C.
D.

12 hours
10 hours
8 hours
4 hours

Situation 19: The nurse is assigned to take care of elderly clients with
different needs while in the medical ward.
91. While examining an elderly female client, the nurse notes musky
sour body odor of the client indicating poor hygiene. Which of the
following is the most appropriate action of the nurse?
A.
B.
C.
D.

Give alcohol rub to cleanse the skin and reduce body

odor
Assist the client to apply moisturizing lotion daily
Obtain prescription for antifungal skin medication
Help client bathe several times weekly

92. The client is weak and needs to be moved up in her bed. To

reduce shearing force when moving the client, the nurse should
A.
B.
C.
D.

Apply lotion to body parts in contact with bed sheet

Give the client a thorough explanation of the process
Ask for staff assistance when lifting the client
Use a draw sheet to put the client in correct position

93. The client has been on bed rest and has reddening of the skin of
bony prominences. When moving the client up in bed, the nurse
places her arms across her chest. This is done to
A.
B.
C.
D.

Make the clients body more aligned

Protect the clients extremities during the procedure
Reduce the surface area that will come in contact with
the bed
Make the body more compact to facilitate the move

94. The nurse reports that a client appears uncomfortable and covers
herself with bed sheets on a warm day. The nurse asks
permission to pull out the sheet but noted urine smell and wet bed
sheets. She persuades the client to get up and shower. The client
refuses and becomes teary-eyed. The most appropriate
therapeutic statement by the nurse would be:
A.
B.
C.

Just allow me to clean you up and you will see how

good I am at this kind of nursing procedure.
You should not be embarrassed since I am used to
taking care of clients who are incontinent.
I am here to make you feel comfortable.

D.

I understand how you feel but it is my responsibility to

take care of you.

95. The client agrees to take a shower. While the client is being
assisted to the bathroom, she begins to fall. Which of the
following should be the initial action of the nurse?
A.
B.
C.
D.

Call for immediate help

Quickly assist the client in a nearby chair and lower the
head between the knees
Call the relatives to get back the client to bed
Refer the client to attending physician

Situation 20: Understanding clients needs depends upon the ability of the
nurse to communicate therapeutically.
96. A client in her early 20s was recently diagnosed with breast
cancer. She says to the nurse, Why did this happen to me? Do I
deserve this when I have been very good to others? Which of the
following should be the appropriate action of the nurse?
A.
B.
C.
D.

Provide comfort by telling her that she doesnt deserve

this
Provide reassurance by recognizing how difficult her
situation must be
Call the chaplain to assist the client in accepting her
fate
Encourage her to seek another opinion

97. The nurse found a 28-year-old client who had hysterectomy

crying while alone in her room. What should be the nurses initial
approach?
A.
B.
C.
D.

Ask her what seems to be troubling her

Reassure her that crying is a normal reaction
Reassure her that her attending physician will order
hormonal replacement therapy
Leave the room quietly

98. The doctor orders the insertion of a nasogastric tube for a client
who refused to eat. She has severe weight loss. She removed the
tube and says, I dont need that thing. The most appropriate
nursing response is
A.
B.
C.
D.

Do you want your condition to deteriorate further?

Why did you pull out the tube?
You should not have done that. You need to improve
your condition.
Your doctor will be upset and order reinsertion of the
tube.
Tell me what you dont like about the tube.

99. A client is admitted to the hospital for diabetes accompanied by

her son. The son is telling the nurse about his difficulty in taking
care of his mother. The nurse is using non-therapeutic
communication when she says
A.
B.
C.
D.

Maybe putting her in a home for the elderly people will

be best for her.
Lets look more closely about your concern.
It appears that you are concerned with your mother.
You seem to be anxious about this. Tell me more
about your concerns.

100. The nurse is establishing her presence as part of her nursing

care. This is best interpreted as
A.
B.
C.
D.

Being with the client always

Offering of closeness with the client physically,
psychologically and spiritually
Personally performing nursing care activities for the
client
Sharing vital information with the client